Brill‐Zinsser Disease in a Patient Following Infection with Sylvatic Epidemic Typhus Associated with Flying Squirrels

Abstract

Recrudescent Rickettsia prowazekii infection, also known as Brill-Zinsser disease, can manifest decades after untreated primary infection but is rare in contemporary settings. We report the first known case of Brill-Zinsser disease in a patient originally infected with a zoonotic strain of R. prowazekii acquired from flying squirrels.

Trends in clinical diagnoses of typhus group rickettsioses among a large U.S. insurance claims database

“…Yet, more patients in the MarketScan® population were diagnosed with epidemic typhus each year than the combined published cases of epidemic typhus in the last four decades. Similarly, while the number of patients in MarketScan® diagnosed with Brill–Zinsser each year was low (average 10.5 cases/year), this greatly exceeds the seven documented U.S. cases of Brill–Zinsser published since 1970 (McQuiston et al, ). Thirteen Brill–Zinsser patients were under the age of 18 years, including diagnoses in 1‐ and 2‐year‐old patients.…”

“…Case fatality rates of 15% have been reported in modern, large‐scale outbreaks of epidemic typhus (Raoult et al, ). Recrudescent infection with R. prowazekii , known as Brill–Zinsser disease, can occur years or decades after primary epidemic typhus infection (Bechah et al, ; McQuiston et al, ). Stress or waning immunity likely plays a role in the re‐activation of persistent R. prowazekii (Bechah et al, ).…”

“…No patients have died from epidemic typhus associated with flying squirrels (Epidemic typhus associated with flying squirrels‐‐United States, ; The Centers for Disease Control, ). Despite the shifting ecology, epidemic typhus is a rarely described disease, and only ≈50 U.S. cases of epidemic typhus from flying squirrel exposure have been documented (Agger & Songsiridej, ; Chapman et al, ; Duma et al, ; McQuiston et al, ).…”

Genome Sequencing of Four Strains of Rickettsia prowazekii, the Causative Agent of Epidemic Typhus, Including One Flying Squirrel Isolate

“…Rickettsia prowazekii is the causative agent of epidemic typhus, vectored primarily by the human body louse, and sylvatic epidemic typhus, which is associated in the United States with contact with the southern flying squirrel, Glaucomys volans . Although improved hygiene has mostly eradicated louse-borne epidemic typhus in the United States, there have been a number of sporadic cases of sylvatic epidemic typhus associated with flying squirrels (2–4). …”

Brill-Zinsser Disease in Moroccan Man, France, 2011

“…Since 1970, reports of only 8 cases of Brill-Zinsser disease have been published ( 9 , 10 ). In all cases, known risk factors were present (overcrowding, poor hygiene, or contact with flying squirrels).…”